July 17, 2012 | 1

Dr. Paul Strengers

Sanquin Blood Supply

Amsterdam, The Netherlands

INTERNATIONAL SEMINAR – FIODS

Management of Best Standards and Practices

for Safe Blood Donations and Transfusions

San Marino, June 23, 2012

Plasma from donors’ perspective

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Blood transfusion is …

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Blood transfusion is …

???

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Blood transfusion is … out of one blood donation

producing many life saving blood products

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Blood transfusion is … maximal use of blood:

1. Centrifugation of blood gives three

layers of blood components

2. Separation of blood cells and plasma

plasma (at the top)

platelets (intermediair layer)

red blood cells (at the bottom)

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Plasma comes available after

whole blood or plasmaferese donation

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Blood transfusion is ….

components and plasma

Plasma

(46-63%)

Particles

(37-54%)

Red blood cells (99.9%)

Platelets

White blood cells

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Blood components and plasma products

Red blood cells

Platelets Blood components

Fresh Frozen Plasma

Albumin

Immunoglobulins

Clotting factors Plasma products/medicines

C1-inhibitor concentrate

Other proteins

Pooling

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Blood components and plasma products

Red blood cells

Platelets Blood components

Fresh Frozen Plasma

Albumin

Immunoglobulins

Clotting factors Plasma products/medicines

C1-inhibitor concentrate

Other proteins

Pooling

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Proteins in plasma are very small … Human

Apple

Ant

Mite

Human hair

Clump

Bacteria

Virus

DNA string Protein

Red blood cel

2-5 microm

10 cm

1 cm

1 mm

0,1 mm

10 µm

100 nm

10 nm

1 nm

1 µm

0,1 nm

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Blood donation is …

participation in the blood and plasma chain:

blood

donor

whole

blood

donation

Red cells,

platelets,

plasma

components

recipients

blood banks fractionation

hospitals

National Regulatory Systems and National Regulatory Authorities

plasma

for

fractionatio-

nation

plasma

derived

medicines

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1/12 of a vial

(1000 I.U. bottle)

(c.a. 480 I.U.)

2.5 vials

(5x10 ml.)

2 vials

(x 10 ml.)

1/12 of a vial

(c.a. 480 I.U )

(100 G. I.U. bottle)

Fraction V Fraction V

Fraction IV

Fraction II

Fraction VIII

Albumin (25 grams)

Factor VIII

200 IUs

Factor IX

275 IUs

Alpha-I Antitrypsin (0.25 grams)

ATIII

Polyvalent IGIV

3-5 grams)

(250 IUs)

ONE

LITER OF

PLASMA

Fraction II

Fraction V

Fraction I

Fraction

IV

PLASMA FRACTIONATION

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The top 10 plasma products

________________________________________________________

Manufacturers (46) → Total Not for profit Commercial

Products ↓ ________________________________________________________

- albumin 46 15 31

- i.v. immunoglobulin 40 10 30

- i.m. / s.c. immunoglobulin 23 9 14

- factor VIII 26 9 17

- factor IX 16 4 12

- prothrombin complex 15 5 10

- antithrombin 14 4 10

- fibrin sealant 9 2 7

- fibrinogen 7 1 6

- alpha-1 antitrypsin 5 2 3

_______________________________________________________ Sources: Marketing Research Bureau, 2008 Manufacturers’ websites

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Plasma contains ….?

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Plasma

Water (92%) Transports, organic and inorganic

molecules, formed elements, and heat

Plasma

Proteins (7%)

Albumins (60%): Contribute to plasma

osmotic pressure; transport lipids,

steroid hormones

Globulins (35%): Transport ions,

hormones, lipids; immune function

Clotting factors (4%): Essential

component of clotting system

Regulatory Proteins (<1%): Enzymes, Hormones Other Solutes (1%)

Electrolytes: Ions necessary for vital cellular activity. Contribute to

osmotic pressure of body fluids. Major electrolytes are Na+,K+,

Ca2+, Mg2+, Cl-, HCO3-, HPO4

2-, SO42-

Organic Nutrients: Used for ATP production, cell growth and

maintenance; Includes lipids, carbohydrates, and amino acids

Organic Wastes: Carried to sites of breakdown or excretion; Includes

urea, uric acid, creatinine, bilirubin, and ammonium ions

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How safe is plasma donation

for the donor ?

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Blood / Plasma donations

Impact of frequency of donations ?

• Collection method:

whole blood vs. apheresis donation

standard vs. hyper-immune plasma

• Donor remuneration status:

unpaid, compensated or paid

• Volume range:

recovered plasma : 450 (±10%) to 500 (±10%) ml/donation

source plasma : 400 to 800 ml/donation

• Donation frequency:

whole blood : 3 to 5 times/year

plasma : 15 to 104 times/year

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Authorized volume ranges:

• EU Directive (2004)

- 650 ml (incl. anticoagulant) to 750 ml (excl. anticoagulant) per procedure

- max. 25 L per year

- 48-hour interval between two donations

Some EU countries

- max. 15 L per year

• German Guidelines (2005)

- 850 ml per session (incl. anticoagulant)

- max. 28.5 L per year

- 48-hour interval between two donations

• FDA/CBER Guidelines for automated plasmapheresis (1992)

- 690 ml (50 – 67,5 kg b.w) to 880 ml (>79 kg b.w.) (incl. anticoagulant)

- frequency limited to twice a week

- 48-hour interval between two donations

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Impact of frequency of donations ?

• What was known?

Compared to whole blood donations or moderate serial plasmapheresis donations, frequent

plasmapheresis donations contain:

- lower levels of IgG, IgA, IgM

- lower levels of albumin

- lower levels of total protein

- higher levels of clotting factors

Question : Impact of frequency of donations ?

• Specific protein content of pools of plasma from fractionation:

comparison of 15 relevant plasma protein markers

Group I : unpaid, recovered, Finland, France, Germany, Belgium. The Netherlands.

Group II : unpaid, recovered, US.

Group III : compensated, source, Germany

Group IV : paid, source, US

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Donation plasma volume

Recovered plasma Source plasma

• EU (Group I): 302 ± 18 m 608 ± 37 m

• Germany (Group III) 657 ± 95 ml 24% higher

• US ( Group IV) 814 ± 13 ml 34% higher

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Proteins studied

• Major plasma-derived products:

Albumin

IgG (in intravenous, intramuscular and subcutaneous immunoglobulins)

C1-esterase inhibitor

• Humoral immune status (indicators of the human immune system)

Immunoglobulin G (IgG)

Immunoglobulin M (IgM)

• Key indicator of the iron transport system

Transferrin (TRF)

• Acute phase inflammation indicator

alpha-1 glycoprotein (AGP)

C-reactive protein (CRP)

• Scavanger of the toxic heme released or lost by heme proteins such as haemoglobin

Hemopexin (HPX)

• Proteins studied in long-term plasmapheresis

Immunoglobulin A (IgA)

Pre-albumin (PREALB)

• Indicators of the protein status in nutritional assesments

Retinol-binding protein (RBP)

Pre-albumin (PREALB)

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Results I

• No significant differences between EU plasma (recovered, group I;

source, group I) and US recovered plasma (group III)

• No significant differences in plasma protein content between

donations collected in countries with ethnically different populations

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Results II

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Results II

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Conclusion I

Compared to EU batches, in US high frequency donations were

found :

1) Lower total protein content (9%)

2) IgA and AGP, no significant difference

3) TRF, RBP and HPX, levels up to 11% lower

4) Albumin, IgM and total IgG, with levels 15% to 28% lower

5) Nutritional deficiency indicators RBP, TRF and albumin, with levels

10%, 7% and 15% lower, respectively.

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Variation of protein content with regard to

protein half-life and donation frequency

Period to allow the plasma proteins to be synthesized and replaced,

and to reach again the physiological level.

Half-lives:

• RBP : 12 hours

• IgA and AGP : < 5 days

• HPX and TRF : 7 and 8 days

• HSA and IgG : 15 and 23 days

• IgG1, IgG2, IgG4 : 20 - 21 days

• IgG3 : 7 days

The high frequency of collection and high volume of maximum

800 ml twice a week does not allow a return to the normal level.

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Conclusion II

• The body does not replace the donated plasma within 48 hours, even if the donor

keeps a healthy diet

• Compared to non-donors and Groups I donors, the low plasma protein level in US

frequent plasmapheresis donors might not be indicative of any disease, but it shows

the presence of a not completely healthy condition

Risks for high-frequency, high-volume donors

Relative low level of albumin, then risk for oedema in older donors, donors with

undiagnosed cardiovascular disorders, or donors at risk developing one.

• IgG is the driving force for the manufacturing of IVIG. Yet, the physiological

replacement of IgG is relatively slow and restoration to normal levels takes time.

Better advise, reduce the frequency in order not to jeopardize the humoral health

status of the donor

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Donor vigilance and frequent plasmapheresis

• Comments from commercial industry : not 104 but only 15 donations

per year.

How to explain the striking findings. Were these donors in good health?

• Red cell management during frequent plasmapheresis.

Little attention on impact of blood loss for sampling and loss of residual

blood from bowl and tubing of disposable set.

Without flushing with saline,

- Germany: additional blood loss per annum of 1440 ml (40/year) = 3 WB

donations

- US: additional blood loss per annum of 3744 ml (104/year) = 7 WB

donations

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Blood transfusion

should imply that…

equal attention

should be given

on the safety

of donors,

as of recipients.